Heart failure – colloquially called cardiac insufficiency – (synonyms: Senile heart failure; asthma cardiale; exercise heart failure; cardiac insufficiency; diastolic heart failure; heart failure; cardiovascular insufficiency; myocardial insufficiency; cardiac edema; insufficientia cordis; cardiac anasarca; cardiac asthenia; cardiac dyspnea; cardiac exhaustion; cardiac global insufficiency; cardiac insufficiency; cardiac weakness; cardiac stasis; cardiac congestion; cardiac congestive heart failure; left ventricular failure; myocardial insufficiency; myocardial weakness; systolic heart failure; ICD-10-GM I50. -: Heart failure) refers to inadequate function of the heart in which the myocardium (heart muscle) is no longer capable of delivering an output (cardiac output; HRV) that meets requirements. Classification according to the area of the heart affected:
- Right heart failure (right heart failure).
- Left heart failure (left-sided heart failure)
- Global insufficiency (bilateral insufficiency)
Acute heart failure (AHI; engl. : acute heart failure, AHF) is distinguished from chronic heart failure (CHI; engl. : chronic heart failure, CHF) according to the time course. Chronic heart failure (HF) classified according to pump function:
| HF type | HFrEF | HFmrEF | HFpEF | |
| Criteria | 1 | Symptoms ± sign a | Symptoms ± signs a | Symptoms ± signs a |
| 2 | LVEF < 40 | LVEF 40-49 % | LVEF ≥ 50 % | |
| 3 |
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Legend
- HFrEF: “Heart Failure with reduced Ejection Fraction”; heart failure with reduced ejection fraction/ejection fraction (= systolic heart failure; synonym: isolated systolic dysfunction; systole is the tense and thus blood outflow phase of the heart).
- HFmrEF: “Heart Failure mid-range Ejection Fraction”; “mid-range” heart failure [approximately 10-20% of patients].
- HFpEF: “Heart Failure with preserved Ejection Fraction”; heart failure with preserved ejection fraction (= diastolic heart failure; synonym: diastolic dysfunction; diastole is the slackening and thus blood inflow phase).
- LVEF: left ventricular ejection fraction; ejection fraction (also expulsion fraction) of the left ventricle during a heartbeat.
- LAE: enlargement of the left atrium (left atrial volume index [LAVI] > 34 ml/m2.
- LVH: left ventricular hypertrophy (left ventricular muscle mass index [LVMI] ≥ 115 g/m2 for men and ≥ 95 g/m2 for women).
- A: signs may be absent in early stages of heart failure (esp. HFpEF) and in diuretic-treated patients
- B: BNP > 35 pg/ml and/or NT-proBNP > 125 pg/ml.
- C: decrease in e’ to < 9 cm/s and increase in E:e’ ratio to > 13 (value: < 8 is considered normal).
US authors bring into focus with a consensus document the group of patients with heart failure with decreased ejection fraction (HFrEF), in whom under therapy – in the course of positive structural cardiac changes (reverse remodeling) -, the previously decreased left ventricular ejection fraction (LVEF) recovers at least partially (LVEF 40-50%) or to largely normal values (eg, > 50%). This particular clinical entity is designated HFrecEF (Heart Failure with recovered Ejection Fraction) as follows and is defined by the following criteria:
- Documentation of an LVEF
- Combined with an absolute LVEF improvement of ≥ 10 % and
- A second LVEF measurement with a value > 40%.
Patients in this category, i.e. with recovery of LVEF, are more often female, younger age, heart failure is not due to coronary artery disease (CAD; coronary artery disease), the duration of the disease is shorter and there is less comorbidity (concomitant diseases).The prognosis of patients with HFrecEF in terms of mortality (death rate) seems to be better than in patients with HFrEF and HFpEF. Furthermore, heart failure can be subdivided into:
- Forward failure (“forward failure”) with decreased cardiac output (HRV).
- Backward failure (“backward failure”) in the presence of backpressure anterior to the insufficient ventricle – based on clinic and hemodynamics.
Classification of acute heart failure.
- De novo
- Acute decompensation of chronic heart failure
Depending on the severity, it is called resting or exercise heart failure. Sex ratio: men to women is 1.5: 1 (heart failure regardless of pumping situation); diastolic heart failure or HFpEF (“heart failure with preserved ejection fraction”) is more common in women than in men. Peak incidence: the maximum incidence of heart failure is in the 8th decade of life. The prevalence (disease incidence) is 10% in those over 70 years of age and 1-3% in those 40-50 years of age. The prevalence of asymptomatic diastolic dysfunction (DD) is reported to be 21-27% in the general population; the prevalence of HFpEF is 1.1-1.5%. The incidence (frequency of new cases) of chronic heart failure is approximately 375 cases per 100,000 population per year for men and 290 per 100,000 population per year for women (in Germany). Course and prognosis: Therapy of heart failure is cause-related. Heart failure can either be compensated by physiological (physical) and therapeutic mechanisms or decompensated heart failure is present. Evidence-based therapeutic interventions exist only for heart failure with reduced ejection fraction (HFrEF). Basic therapeutic agents are ACE inhibitors and beta blockers. Severe acute as well as chronic forms of heart failure may be associated with complications such as pulmonary edema (water lung; accumulation of fluid in the lung tissue or alveoli) or cardiogenic shock (pumping failure of the heart), requiring intensive care. Advanced heart failure can ultimately lead to sudden cardiac death. It also increases the risk of thrombus (blood clot) formation, which in turn can lead to pulmonary embolism or apoplexy (stroke). In overweight and mild to moderate obesity, patients with acute and chronic heart failure have a significantly better survival rate compared to normal weight patients (obesity paradox). Although obesity is known to be associated with an increased risk of new-onset heart failure. The prognosis of heart failure depends on the type of heart failure, stage of the disease, and whether other chronic diseases such as diabetes mellitus are present. As expected, the prognosis of patients with “mid-range” heart failure (heart failure mid-range ejection fraction or HFmrEF) at a 3-year follow-up was better compared with HFrEF (heart failure with reduced ejection fraction) patients. They also had significantly lower all-cause mortality compared with HFpEF (heart failure with preserved ejection fraction) patients (RR 0.71; 95% CI 0.55-0.91; p = 0.007), significantly lower cardiovascular mortality (cardiovascular-related mortality rate) (RR 0.50; 95% CI 0.35-0.71; p < 0.001), and significantly fewer heart failure-related hospitalizations (RR 0.48; 95% CI 0.30-0.76; p = 0.002). Better therapies have reduced heart failure mortality (number of deaths in a given time period, relative to the number in the relevant population) by up to 50% over the past decade. Based on a comprehensive data analysis of 56,658 patients with a median age of 69 years, it was shown that one and five years after the diagnosis of heart failure, 14.4 and 62.3 percent of men and 17.7 and 68.1 percent of women, respectively, had died. Mortality is 5-10% (per year) in left heart failure. Ca.50% of people diagnosed with heart failure die within 5 years. In a severe form of progression, mortality of up to 50% can be expected in the first year. Patients with HFpEF have a significantly 38% lower mortality risk than patients with HFrEF (heart failure with reduced ejection fraction; hazard ratio 0.62; p = 0.003). Prognosis: determination of mortality risk (risk of death) using an online prognostic calculator.
Comorbidities: Chronic obstructive pulmonary disease (COPD) and anemia (anemia; 33% of cases) can mask the symptoms of heart failure! The comorbidity of depression is up to 5 times more common in heart failure than in the general population. Similarly, atrial fibrillation is a recognized comorbidity of heart failure: more than half of patients with newly discovered heart failure have atrial fibrillation. Another common comorbidity is sleep apnea in patients with heart failure.